Psoriatic arthritis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

peripheral arthritis

treatment-naive

1st line – conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

1st line –

conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Initial treatment choice for patients with peripheral joint disease is based on severity of disease and/or the patient's response to treatment. Conventional synthetic DMARDs are a suitable first-line option. Recommended first-line treatment varies; check local guidelines.

International guidelines suggest that conventional synthetic DMARDs (methotrexate, sulfasalazine, or leflunomide) may be used as first-line treatment for treatment-naive patients with peripheral arthritis, with regular assessment of clinical response (every 12 to 24 weeks) and early escalation of therapy (between 12 and 24 weeks) advised as necessary.[61]

US guidelines conditionally recommend that a conventional synthetic DMARD should be considered as first-line treatment for patients who are treatment naive without severe psoriatic arthritis (PsA) or severe psoriasis, based on patient preference, or for patients who have contraindications to tumour necrosis factor (TNF)-alpha inhibitors (e.g., congestive heart failure, previous serious infection, recurrent infection, demyelinating disease).[50]

European guidelines recommend a conventional synthetic DMARD as first-line treatment.[60] Methotrexate is preferred, due to ease of administration (i.e., once-weekly dosing) and relatively rapid onset of action, particularly in patients with psoriasis.[60] Alternatives include leflunomide and sulfasalazine, which are less beneficial in treating skin symptoms.[60]

An initial trial of methotrexate should last for 3 months and if the treatment target is not reached within 6 months, a different strategy should be pursued.[60] Methotrexate does not appear to increase the risk of respiratory adverse events in PsA.[66] Folic acid supplementation is required.

One Cochrane review demonstrated that low-dose oral methotrexate for 6 months may be more effective than placebo for PsA patients, although the evidence quality was considered to be low.[67] An absolute improvement of 16% was seen with methotrexate for disease response (using the psoriatic arthritis response criteria), 10% for function (using the health assessment questionnaire), and 3% for mean disease activity (using the disease activity score 28 ESR) compared with placebo.[67]

An alternative conventional synthetic DMARD is conditionally recommended for patients with diabetes, due to an increased risk of liver toxicity and fatty liver disease with methotrexate.[50]

Primary options

methotrexate: 7.5 to 25 mg orally/subcutaneously/intramuscularly once weekly on the same day each week

leflunomide: 10-20 mg orally once daily

sulfasalazine: 1-2 g orally twice daily

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50]

High-impact exercise may also be considered according to patient preference.[50]

Physiotherapy reduces pain, improves range of motion, and strengthens muscles of joints with associated periarticular muscle atrophy. Consequently, patients with limited disease may not necessarily require physiotherapy. Other non-pharmacological treatments that may be beneficial include weight loss in patients who are overweight or obese, occupational therapy, and alternative therapies, such as massage therapy and acupuncture.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

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Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

No studies have demonstrated an advantage of one NSAID over another; choice will depend on patient preference and clinical experience. Examples of commonly used NSAIDs are listed here. Consult your local guidelines for more information.

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular or oral corticosteroid

Back

Consider –

intra-articular or oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Intra-articular corticosteroid injection may be offered as adjunctive therapy for mono- or oligoarthritis.[60][61] The benefit of intra-articular corticosteroid injection for psoriatic arthritis has been demonstrated in an observational cohort study.[64] There is a lack of randomised controlled trial evidence. Long-acting agents such as triamcinolone hexacetonide should be avoided in superficial joints, where there is a high risk of subcutaneous atrophy. In this situation, methylprednisolone acetate is preferred.

International guidelines conditionally recommend systemic corticosteroids.[61] However, there is evidence to suggest that systemic corticosteroids should be avoided, as there is a risk of post-exposure psoriasis flare and an increased risk of cardiovascular disease, even at low doses of <5 mg/day prednisolone.[65] In practice, corticosteroids should be avoided; however, in acute polyarticular arthritis, a brief course of a low-dose oral corticosteroid may be considered to reduce pain/suffering of the patients if clinically appropriate, in conjunction with conventional synthetic DMARDs.

Primary options

methylprednisolone acetate: small joints: 4-10 mg intra-articularly as a single dose; medium joints: 10-40 mg intra-articularly as a single dose; large joints: 20-80 mg intra-articularly as a single dose

Secondary options

prednisolone: 5-60 mg/day orally

1st line – biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

1st line –

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Biological agents (or targeted synthetic DMARDs) are a suitable first-line option in some patients. Recommended first-line treatment varies and this is a rapidly developing area; check local guidelines.

International guidelines recommend biological agents as first-line treatment for peripheral arthritis. Tumour necrosis factor (TNF)-alpha inhibitors may be the preferred first-line therapy for treatment-naive patients, as emergent evidence demonstrated their efficacy over conventional synthetic DMARDs, especially for patients with early disease.[61]

For patients with previous experience of biological agents, TNF-alpha inhibitors, interleukin (IL)-17 inhibitors, and IL-23 inhibitors are strongly recommended to treat patients with an inadequate response to conventional synthetic DMARDs, and abatacept is recommended for patients who experience treatment failure with other biologicals.[50][60][61][68]

TNF-alpha inhibitors are the most widely used group of biological treatments. Etanercept, adalimumab, infliximab, golimumab, and certolizumab have been shown to improve joints, skin, daily function, and rate of progression of radiographic erosions in placebo-controlled randomised controlled trials (RCTs).[69][70] There is some evidence of better adherence to golimumab compared with other TNF-alpha inhibitors in patients with inflammatory arthritis, although guidelines do not recommend one TNF-alpha inhibitor over another.[50][60][71] In patients who have concomitant inflammatory bowel disease or inflammatory eye disease (uveitis), it is strongly recommended that a monoclonal antibody TNF-alpha inhibitor is chosen over etanercept.[50] Contraindications to TNF-alpha inhibitors include congestive heart failure, previous serious or recurrent infections, and demyelinating disease.[50][72] TNF-alpha inhibitors carry a warning against their use in patients with frequent serious infections.[50] Number needed to harm has been calculated as 59 for serious infection (within a treatment period of 3-12 months), and 154 for cancer (within a treatment period of 6-12 months) for patients treated with TNF-alpha inhibitors.[72] Prior to initiation of TNF-alpha inhibitor therapy, a baseline chest x-ray should be obtained, along with an assessment of tuberculin and hepatitis B infection status.

There are several IL inhibitors approved to treat psoriatic arthritis (PsA): the IL-17 inhibitors secukinumab and ixekizumab; the IL-12/23 inhibitor ustekinumab; and the IL-23 inhibitors guselkumab and risankizumab. International guidelines suggest that IL inhibitors may be considered for use after TNF-alpha inhibitors, based on one small trial that demonstrated a lack of superiority of IL inhibition compared with TNF inhibition in peripheral joint domains.[61] European guidelines recommend that IL-17 and IL-12/23 inhibitors may be preferred over other biological agents when a patient has relevant skin involvement.[60] US guidelines conditionally recommend secukinumab and ixekizumab for use after TNF-alpha inhibitors, but note that they may be used earlier if there are contraindications to TNF-alpha inhibitors or in patients with severe psoriasis.[50][68] They are not recommended in patients who have concomitant inflammatory bowel disease due to a lack of evidence for their effectiveness.[50] A 52-week RCT comparing secukinumab and adalimumab found similar ACR20 response rates between groups.[73] An open-label trial comparing ixekizumab with adalimumab found similar ACR50 response rates at 24 weeks.[74] Ustekinumab is conditionally recommended for use after secukinumab and ixekizumab; however, it may show benefit if used earlier in patients with concomitant inflammatory bowel disease or those who prefer less frequent dosing.[50] Guselkumab and risankizumab have both demonstrated efficacy and safety versus placebo in phase 3 studies, with sustained improvements reported up to 52 weeks.[75][76][77][78][79] IL-23 inhibitors provide a further treatment option in patients with an inadequate response or intolerance to at least one conventional synthetic DMARD, although they are not yet included in many treatment guidelines. The National Institute for Health and Care Excellence in the UK recommends risankizumab alone or with methotrexate as an option for adults with active PsA (with ≥3 tender and ≥3 swollen joints and psoriasis that is moderate to severe [body surface area ≥3% and Psoriasis Area and Severity Index {PASI} >10]), who have experienced treatment failure or are intolerant to two conventional synthetic DMARDs and at least one biological agent.[82] Although the efficacy of IL inhibitors in rheumatological conditions is established, they are associated with an increased risk of serious infections, opportunistic infections, and cancer.[84][85] Number needed to harm has been calculated as 67 for serious infection (within a treatment period of 3-12 months), and 250 for cancer (within a treatment period of 6-12 months) for patients treated with IL inhibitors.[72][84] However, the US Food and Drug Administration (FDA) considers IL inhibitors to carry less risk of infection than TNF-alpha inhibitors.

In patients with peripheral arthritis who have an inadequate response to at least one conventional synthetic DMARD and at least one biological agent, or when a biological agent is not appropriate, a Janus kinase (JAK) inhibitor (e.g., tofacitinib, upadacitinib) may be considered.[60][61]

Results from a large randomised safety clinical trial comparing tofacitinib with TNF-alpha inhibitors in patients with rheumatoid arthritis who were 50 years of age or older and had at least one other cardiovascular risk factor found an increased risk of death, blood clots, myocardial infarction, and cancer with the lower dose of tofacitinib (5 mg twice daily); this serious event had previously been reported only with the higher dose (10 mg twice daily) in the preliminary analysis.[88]

Subsequently, the FDA, the European Medicines Agency (EMA), and the UK's Medicines and Healthcare products Regulatory Agency (MHRA) have issued warnings about the increased risk of serious cardiovascular events, malignancy, thrombosis, and death with JAK inhibitors compared with TNF-alpha inhibitors.[89][90][91] The FDA advises clinicians to reserve JAK inhibitors for patients who have had an inadequate response or are intolerant to one or more TNF-alpha inhibitors, and to consider the patient’s individual benefit-risk profile when deciding to prescribe or continue treatment with these medications, particularly in patients who are current or past smokers, patients with other cardiovascular risk factors, those who develop a malignancy, and those with a known malignancy (other than a successfully treated non-melanoma skin cancer).[89]

Apremilast is recommended as either first-line therapy for treatment-naive patients, or as treatment for patients who experience an inadequate response to at least one conventional synthetic DMARD.[50][60][61]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

Secondary options

secukinumab: no plaque psoriasis (with loading dose): 150 mg subcutaneously at 0, 1, 2, 3, and 4 weeks, then 150 mg every 4 weeks, may increase to 300 mg every 4 weeks if arthritis persists; no plaque psoriasis (without loading dose): 150 mg subcutaneously every 4 weeks, may increase to 300 mg every 4 weeks if arthritis persists; with plaque psoriasis: 300 mg subcutaneously at 0, 1, 2, 3, and 4 weeks, then 150-300 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

ustekinumab: no plaque psoriasis: 45 mg subcutaneously at 0 and 4 weeks, then 45 mg every 12 weeks; plaque psoriasis and body weight >100 kg: 90 mg subcutaneously at 0 and 4 weeks, then 90 mg every 12 weeks

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then 100 mg every 8 weeks

risankizumab: 150 mg subcutaneously at weeks 0 and 4, then 150 mg every 12 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

apremilast: 10 mg orally once daily on day 1, followed by 10 mg twice daily on day 2, then 10 mg in the morning and 20 mg in the evening on day 3, then 20 mg twice daily on day 4, then 20 mg in the morning and 30 mg in the evening on day 5, then 30 mg twice daily on day 6 and thereafter

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50]

High-impact exercise may also be considered according to patient preference.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid injection

Back

Consider –

intra-articular corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Primary options

inadequate response to conventional synthetic DMARD

1st line – switch to biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

1st line –

switch to biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

International guidelines recommend biological agents (or targeted synthetic DMARDs) in patients who have not responded to at least one conventional synthetic DMARD.[60][61]

Tumour necrosis factor (TNF)-alpha inhibitors are the most widely used group of biological treatments. Etanercept, adalimumab, infliximab, golimumab, and certolizumab have been shown to improve joints, skin, daily function, and rate of progression of radiographic erosions in placebo-controlled randomised controlled trials (RCTs).[69][70] There is some evidence of better adherence to golimumab compared with other TNF-alpha inhibitors in patients with inflammatory arthritis, although guidelines do not recommend one TNF-alpha inhibitor over another.[50][60][71] In patients who have concomitant inflammatory bowel disease or inflammatory eye disease (uveitis), it is strongly recommended that monoclonal antibody TNF-alpha inhibitors are chosen over etanercept.[50] Contraindications to TNF-alpha inhibitors include congestive heart failure, previous serious or recurrent infections, and demyelinating disease.[50][72] TNF-alpha inhibitors carry a warning against their use in patients with frequent serious infections.[50] Number needed to harm has been calculated as 59 for serious infection (within a treatment period of 3-12 months), and 154 for cancer (within a treatment period of 6-12 months) for patients treated with TNF-alpha inhibitors.[72] Prior to initiation of TNF-alpha inhibitor therapy, a baseline chest x-ray should be obtained, along with an assessment of tuberculin and hepatitis B infection status.

There are several interleukin (IL) inhibitors approved to treat psoriatic arthritis (PsA): the IL-17 inhibitors secukinumab and ixekizumab; the IL-12/23 inhibitor ustekinumab; and the IL-23 inhibitors guselkumab and risankizumab. International guidelines suggest that IL inhibitors may be considered for use after TNF-alpha inhibitors, based on one small trial that demonstrated a lack of superiority of IL inhibition compared with TNF inhibition in peripheral joint domains.[61] European guidelines recommend that IL-17 and IL-12/23 inhibitors may be preferred over other biological agents when a patient has relevant skin involvement.[60] US guidelines conditionally recommend secukinumab and ixekizumab for use after TNF-alpha inhibitors, but note that they may be used earlier if there are contraindications to TNF-alpha inhibitors or in patients with severe psoriasis.[50][68] They are not recommended in patients who have concomitant inflammatory bowel disease due to a lack of evidence for their effectiveness.[50] A 52-week RCT comparing secukinumab and adalimumab found similar ACR20 response rates between groups.[73] An open-label trial comparing ixekizumab with adalimumab found similar ACR50 response rates at 24 weeks.[74] Ustekinumab is conditionally recommended for use after secukinumab and ixekizumab; however, it may show benefit if used earlier in patients with concomitant inflammatory bowel disease or those who prefer less frequent dosing.[50] Guselkumab and risankizumab have both demonstrated efficacy and safety versus placebo in phase 3 studies, with sustained improvements reported at 1 and 2 years in both treatments.[75][76][77][78][79][80][81] IL-23 inhibitors provide a further treatment option in patients with an inadequate response or intolerance to at least one DMARD, although they are not yet included in many treatment guidelines. The National Institute for Health and Care Excellence in the UK recommends guselkumab or risankizumab alone or with methotrexate as an option for adults with active PsA (with ≥3 tender and ≥3 swollen joints and psoriasis that is moderate to severe [body surface area ≥3% and Psoriasis Area and Severity Index {PASI} >10]), who have experienced treatment failure or are intolerant to two conventional synthetic DMARDs and at least one biological agent.[82][83] If guselkumab is being considered, a biological agent need not be trialled if TNF-alpha inhibitors are contraindicated.[83] Although the efficacy of IL inhibitors in rheumatological conditions is established, they are associated with an increased risk of serious infections, opportunistic infections, and cancer.[84][85] Number needed to harm has been calculated as 67 for serious infection (within a treatment period of 3-12 months), and 250 for cancer (within a treatment period of 6-12 months) for patients treated with IL inhibitors.[72][84] However, the US Food and Drug Administration (FDA) considers IL inhibitors to carry less risk of infection than TNF-alpha inhibitors.

The FDA, the European Medicines Agency (EMA), and the UK's Medicines and Healthcare products Regulatory Agency (MHRA) have issued warnings about the increased risk of serious cardiovascular events, malignancy, thrombosis, and death with JAK inhibitors compared with TNF-alpha inhibitors.[89][90][91] The FDA advises clinicians to reserve JAK inhibitors for patients who have had an inadequate response or are intolerant to one or more TNF-alpha inhibitors, and to consider the patient’s individual benefit-risk profile when deciding to prescribe or continue treatment with these medications, particularly in patients who are current or past smokers, patients with other cardiovascular risk factors, those who develop a malignancy, and those with a known malignancy (other than a successfully treated non-melanoma skin cancer).[89]

Apremilast is recommended as treatment for patients who experience an inadequate response to conventional synthetic DMARD treatment.[50][60][61]

Abatacept is conditionally recommended for patients who experience treatment failure with conventional synthetic DMARDs.[60][61] In the US, abatacept can be considered for patients with active disease despite treatment with TNF-alpha inhibitors, instead of switching to a different TNF-alpha inhibitor, or for patients with recurrent or severe infection who do not have severe psoriasis.[50][68] Evidence from RCTs suggests that abatacept significantly improved ACR20 response at 24 weeks versus placebo.[86][87]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then 100 mg every 8 weeks

risankizumab: 150 mg subcutaneously at weeks 0 and 4, then 150 mg every 12 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

Secondary options

abatacept: 125 mg subcutaneously once weekly; consult specialist for guidance on intravenous dose

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50]

High-impact exercise may also be considered according to patient preference.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid injection

Back

Consider –

intra-articular corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Primary options

2nd line – switch to alternative conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

2nd line –

switch to alternative conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

If the patient has an inadequate response to initial conventional synthetic DMARD treatment, switching to an alternative conventional synthetic DMARD is conditionally recommended.[61]

One Cochrane review demonstrated that low-dose oral methotrexate for 6 months may be more effective than placebo for psoriatic arthritis patients, although the evidence quality was considered to be low.[67] An absolute improvement of 16% was seen with methotrexate for disease response (using the psoriatic arthritis response criteria), 10% for function (using the health assessment questionnaire), and 3% for mean disease activity (using the disease activity score 28 ESR) compared with placebo.[67]

An alternative conventional synthetic DMARD is conditionally recommended for patients with diabetes, due to an increased risk of liver toxicity and fatty liver disease with methotrexate.[50]

Primary options

methotrexate: 7.5 to 25 mg orally/subcutaneously/intramuscularly once weekly on the same day each week

leflunomide: 10-20 mg orally once daily

sulfasalazine: 1-2 g orally twice daily

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50]

High-impact exercise may also be considered according to patient preference.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular or oral corticosteroid

Back

Consider –

intra-articular or oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

Secondary options

prednisolone: 5-60 mg/day orally

inadequate response to initial biological

1st line – switch to another biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

1st line –

switch to another biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

If patients do not respond to initial biological agents or targeted synthetic DMARD treatment, switching to a tumour necrosis factor (TNF)-alpha inhibitor, interleukin (IL)-17 inhibitor, IL-23 inhibitor, or Janus kinase (JAK) inhibitor is strongly recommended, while IL-12/23 inhibitors, abatacept, and the targeted synthetic DMARD apremilast are conditionally recommended as alternatives.[61]

Etanercept, adalimumab, infliximab, golimumab, and certolizumab have been shown to improve joints, skin, daily function, and rate of progression of radiographic erosions in placebo-controlled randomised controlled trials (RCTs).[69][70] Contraindications to TNF-alpha inhibitors include congestive heart failure, previous serious or recurrent infections, and demyelinating disease.[50][72] TNF-alpha inhibitors carry a warning against their use in patients with frequent serious infections.[50] Number needed to harm has been calculated as 59 for serious infection (within a treatment period of 3-12 months), and 154 for cancer (within a treatment period of 6-12 months) for patients treated with TNF-alpha inhibitors.[72] Prior to initiation of TNF-alpha inhibitor therapy, a baseline chest x-ray should be obtained, along with an assessment of tuberculin and hepatitis B infection status.

There are several IL inhibitors approved to treat psoriatic arthritis (PsA): the IL-17 inhibitors secukinumab and ixekizumab; the IL-12/23 inhibitor ustekinumab; and the IL-23 inhibitors guselkumab and risankizumab. Secukinumab, ixekizumab, guselkumab, and risankizumab are recommended as primary options here, while ustekinumab is conditionally recommended as an alternative treatment.[61]

A 52-week RCT comparing secukinumab and adalimumab found similar ACR20 response rates between groups.[73] An open-label trial comparing ixekizumab with adalimumab found similar ACR50 response rates at 24 weeks.[74] Ustekinumab is conditionally recommended for use after secukinumab and ixekizumab; however, it may show benefit if used earlier in patients with concomitant inflammatory bowel disease or those who prefer less frequent dosing.[50] Guselkumab and risankizumab have both demonstrated efficacy and safety versus placebo in phase 3 studies, with sustained improvements reported at 1 and 2 years in both treatments.[75][76][77][78][79][80][81]

The National Institute for Health and Care Excellence in the UK recommends guselkumab or risankizumab alone or with methotrexate as an option for adults with active PsA (with ≥3 tender and ≥3 swollen joints and psoriasis that is moderate to severe [body surface area ≥3% and Psoriasis Area and Severity Index {PASI} >10]), who have experienced treatment failure or are intolerant to two conventional synthetic DMARDs and at least one biological agent.[82][83] If guselkumab is being considered, a biological agent need not be trialled if TNF-alpha inhibitors are contraindicated.[83] Although the efficacy of IL inhibitors in rheumatological conditions is established, they are associated with an increased risk of serious infections, opportunistic infections, and cancer.[84][85] Number needed to harm has been calculated as 67 for serious infection (within a treatment period of 3-12 months), and 250 for cancer (within a treatment period of 6-12 months) for patients treated with IL inhibitors.[72][84] However, the US Food and Drug Administration (FDA) considers IL inhibitors to carry less risk of infection than TNF-alpha inhibitors.

In patients with peripheral arthritis who have an inadequate response to at least one conventional synthetic DMARD and at least one biological agent, or when a biological agent is not appropriate, a JAK inhibitor (e.g., tofacitinib, upadacitinib) may be considered.[60][61]

Apremilast and abatacept should be considered in patients with an inadequate response to initial biological agent or targeted synthetic DMARD treatment.[60][61]

Evidence from RCTs suggests that abatacept significantly improved ACR20 response at 24 weeks versus placebo.[86][87]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then 100 mg every 8 weeks

risankizumab: 150 mg subcutaneously at weeks 0 and 4, then 150 mg every 12 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

Secondary options

abatacept: 125 mg subcutaneously once weekly; consult specialist for guidance on intravenous dose

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50]

High-impact exercise may also be considered according to patient preference.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid injection

Back

Consider –

intra-articular corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Intra-articular corticosteroid injection may be offered as adjunctive therapy for mono- or oligoarthritis.[60] The benefit of intra-articular corticosteroid injection for psoriatic arthritis has been demonstrated in an observational cohort study.[64] There is a lack of randomised controlled trial evidence. Long-acting agents such as triamcinolone hexacetonide should be avoided in superficial joints, where there is a high risk of subcutaneous atrophy. In this situation, methylprednisolone acetate is preferred.

Primary options

axial disease

1st line – non-steroidal anti-inflammatory drug (NSAID)

Back

1st line –

non-steroidal anti-inflammatory drug (NSAID)

NSAIDs may be used to relieve musculoskeletal symptoms of psoriatic arthritis (PsA), with careful consideration of the risk:benefit ratio, in view of the increased cardiovascular risk in patients with PsA.[60] However, symptom relief, for the most part, is only partial with NSAIDs. US guidelines recommend NSAIDs for patients who do not have severe PsA or severe psoriasis, and for those who are at risk of liver toxicity.[50] NSAID monotherapy should not be used for more than 1 month if symptoms persist.[60]

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Low-impact exercise is also recommended for patients without contraindications, such as existing muscle/tendon injury or multiple inflamed joints with pain that is worse with exercise.[50] High-impact exercise may also be considered according to patient preference.[50]

Consider – intra-articular corticosteroid injection

Back

Consider –

intra-articular corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Primary options

2nd line – biological agent or Janus kinase (JAK) inhibitor

Back

2nd line –

biological agent or Janus kinase (JAK) inhibitor

Biological agents (tumour necrosis factor [TNF]-alpha inhibitors, interleukin [IL]-17 inhibitors) or JAK inhibitors are recommended for patients with axial symptoms who have not responded to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and supportive measures.[50][60][61]

No TNF-alpha inhibitor is recommended over any other for the typical patient.[50] However, infliximab is not recommended for patients with an increased risk of tuberculosis exposure or a history of recurrent infections. In patients with recurrent uveitis or inflammatory bowel disease, monoclonal antibody TNF-alpha inhibitors are recommended over etanercept.[50][60] Patients who relapse after initially responding to one TNF-alpha inhibitor should be switched to a second TNF-alpha inhibitor.[50][60]

The IL-17 inhibitors secukinumab and ixekizumab are recommended for patients with severe psoriasis or contraindications to TNF-alpha inhibitors, or for those who are primary non-responders to TNF-alpha inhibitors.[50][60] Secukinumab has been specifically evaluated for efficacy in axial manifestations of psoriatic arthritis and demonstrated significant improvements compared with placebo for both signs and symptoms of axial disease and objective measures of axial inflammation.[92] Both ixekizumab and secukinumab are indicated for the treatment of axial spondyloarthritis.

The JAK inhibitors tofacitinib and upadacitinib are indicated for ankylosing spondylitis for patients who have had an inadequate response or are intolerant to one or more TNF-alpha inhibitors.[61] Tofacitinib showed a significant benefit in axial symptoms in one phase 3 study and is an option in patients with co-existing ulcerative colitis if TNF-alpha inhibitors are not an option.[93][94] The US Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the UK's Medicines and Healthcare products Regulatory Agency (MHRA) have issued warnings about the increased risk of serious cardiovascular events, malignancy, thrombosis, and death with JAK inhibitors compared with TNF-alpha inhibitors.[89][90][91] The FDA advises clinicians to reserve JAK inhibitors for patients who have had an inadequate response or are intolerant to one or more TNF-alpha inhibitors, and to consider the patient's individual benefit-risk profile when deciding to prescribe or continue treatment with these medications, particularly in patients who are current or past smokers, patients with other cardiovascular risk factors, those who develop a malignancy, and those with a known malignancy (other than a successfully treated non-melanoma skin cancer).[89]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs may need to be continued in some patients. NSAIDs may be used to relieve musculoskeletal symptoms of psoriatic arthritis (PsA), with careful consideration of the risk:benefit ratio, in view of the increased cardiovascular risk in patients with PsA.[60]

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid injection

Back

Consider –

intra-articular corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Primary options

enthesitis

1st line – non-steroidal anti-inflammatory drug (NSAID)

Back

1st line –

non-steroidal anti-inflammatory drug (NSAID)

NSAIDs are commonly used as first-line therapy for enthesitis, especially for localised enthesitis.[61] They should be used with careful consideration of the risk:benefit ratio, in view of the increased cardiovascular risk in patients with psoriatic arthritis (PsA).[60] However, symptom relief, for the most part, is only partial with NSAIDs.

US guidelines recommend NSAIDs for patients who do not have severe PsA or severe psoriasis, and for those who are at risk of liver toxicity.[50] NSAID monotherapy should not be used for more than 1 month if symptoms persist.[60]

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – intra-articular corticosteroid

Back

Consider –

intra-articular corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

2nd line – biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

2nd line –

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Tumour necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors, Janus kinase (JAK) inhibitors, and apremilast are recommended as options to treat patients who have an inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs).[61] Abatacept is conditionally recommended as an alternative option.[61]

In patients who have predominant enthesitis, US guidelines conditionally recommend that TNF-alpha inhibitors and tofacitinib are used as initial treatment.[50] Apremilast is recommended as an alternative for patients who have contraindications to these medications, or as an alternative to NSAIDs in patients with severe psoriasis. Patients who have an inadequate response or contraindications to TNF-alpha inhibitors or who have severe psoriasis may benefit from IL-17 inhibitors, or from IL-12/23 inhibitors if they have inflammatory bowel disease or prefer less frequent drug administration.[50]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then 100 mg every 8 weeks

risankizumab: 150 mg subcutaneously at weeks 0 and 4, then 150 mg every 12 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

Secondary options

abatacept: 125 mg subcutaneously once weekly; consult specialist for guidance on intravenous dose

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid

Back

Consider –

intra-articular corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

3rd line – conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

3rd line –

conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Conventional synthetic DMARDs are conditionally recommended for the treatment of active enthesitis in some countries, but in others (including the US) they are not recommended for patients with predominant enthesitis.[50][61]

Methotrexate is the preferred conventional synthetic DMARD, due to ease of administration (i.e., once-weekly dosing) and relatively rapid onset of action, particularly in patients with psoriasis.[60] A trial of methotrexate should last for 3 months and if the treatment target is not reached within 6 months, a different strategy should be pursued.[60] Methotrexate does not appear to increase the risk of respiratory adverse events in psoriatic arthritis.[66] Daily folic acid supplements are required.

Primary options

methotrexate: 7.5 to 25 mg orally/subcutaneously/intramuscularly once weekly on the same day each week

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid

Back

Consider –

intra-articular corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

dactylitis

1st line – biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

1st line –

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Dactylitis (inflammation of the whole digit) in psoriatic arthritis (PsA) is associated with disease severity and an increased risk of radiographic progression, particularly in men.[60][95]

Tumour necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors, Janus kinase (JAK) inhibitors, and apremilast are recommended as treatment options for dactylitis in PsA, with abatacept conditionally recommended as an alternative option.[61]

Evidence from meta-analyses demonstrates that both TNF-alpha inhibitors and IL inhibitors are effective in resolving dactylitis compared with placebo, and that both treatments are associated with higher dactylitis resolution rates.[95][96] Analysis of dactylitis outcomes in patients with PsA in subsequent trials report significantly more resolution for guselkumab and ixekizumab compared with placebo, and golimumab with methotrexate compared with methotrexate monotherapy.[97][98]

Primary options

etanercept: 50 mg subcutaneously once weekly; or 25 mg subcutaneously twice weekly

adalimumab: 40 mg subcutaneously every 2 weeks

infliximab: 5 mg/kg intravenously at 0, 2, and 6 weeks, then every 8 weeks

golimumab: 50 mg subcutaneously once monthly; 2 mg/kg intravenously at 0 and 4 weeks, then every 8 weeks

certolizumab pegol: 400 mg subcutaneously at 0, 2, and 4 weeks, then 200 mg every 2 weeks or 400 mg every 4 weeks

ixekizumab: 160 mg subcutaneously at week 0, then 80 mg every 4 weeks

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then 100 mg every 8 weeks

risankizumab: 150 mg subcutaneously at weeks 0 and 4, then 150 mg every 12 weeks

tofacitinib: 5 mg orally (immediate-release) twice daily; 11 mg orally (extended-release) once daily

upadacitinib: 15 mg orally once daily

Secondary options

abatacept: 125 mg subcutaneously once weekly; consult specialist for guidance on intravenous dose

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid

Back

Consider –

intra-articular corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

2nd line – conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Back

2nd line –

conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Although there is a lack of clinical trials to specifically evaluate therapeutic interventions for dactylitis, methotrexate has shown some efficacy, and is conditionally recommended to treat dactylitis.[60][61]

However, US guidelines suggest that a conventional synthetic DMARD should be considered, with progression to biological agents in patients with an inadequate response at 3-6 months.[50][60]

Primary options

methotrexate: 7.5 to 25 mg orally/subcutaneously/intramuscularly once weekly on the same day each week

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Smoking cessation is strongly recommended for all patients, particularly in view of the increased risk of cardiovascular disease with psoriatic arthritis.[50]

Consider – non-steroidal anti-inflammatory drug (NSAID)

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID)

Additional treatment recommended for SOME patients in selected patient group

Primary options

naproxen: 250-500 mg orally twice daily, maximum 1500 mg/day

ibuprofen: 300-600 mg orally three to four times daily when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) three to four times daily, maximum 200 mg/day

Consider – intra-articular corticosteroid

Back

Consider –

intra-articular corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Primary options

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Psoriatic arthritis

Treatment algorithm

peripheral arthritis

conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular or oral corticosteroid

Primary options

Secondary options

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

Secondary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid injection

Primary options

switch to biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

Secondary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid injection

Primary options

switch to alternative conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular or oral corticosteroid

Primary options

Secondary options

switch to another biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

Secondary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid injection

Primary options

axial disease

non-steroidal anti-inflammatory drug (NSAID)

Primary options

supportive measures

intra-articular corticosteroid injection

Primary options

biological agent or Janus kinase (JAK) inhibitor

Primary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid injection

Primary options

enthesitis

non-steroidal anti-inflammatory drug (NSAID)

Primary options

supportive measures

intra-articular corticosteroid

Primary options

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

Secondary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid

Primary options

conventional synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options

supportive measures

non-steroidal anti-inflammatory drug (NSAID)

Primary options

intra-articular corticosteroid

Primary options

dactylitis

biological agent or targeted synthetic disease-modifying anti-rheumatic drug (DMARD)

Primary options